Authoring Patient Records: An Interactive Guide presents both the theory and rationale for the process of developing medical records, as well as opportunities for readers to practice the new skill. Each chapter discusses how to use the authoring process to create effective records, using examples and sample documents to help illustrate potential problems and solutions. This text has an interactive format including margin notes to help the reader assess his/her understanding, as well as opportunities to practice the authoring process being discussed. An instructor’s manual for online use is also included.
Authoring Patient Records: An Interactive Guide is relevant to the training and work of: MDs, PAs, NPs, RNs, PTs, and RTs. This text is a helpful resource in teaching health care students and as a reference for health care practitioners.
- Theory and rationale for the process of authoring a medical record
- Examples showing proper documentation
- Practice assignments
- Instructor guide with online worksheets
- Commonly used forms to download
Table of Contents
Chapter 1 The Patient Record – An Overview
Chapter 2 Audience, Purpose, and Use
Chapter 3 Developing an Authoring Process
Chapter 4 Adapting the Reporter’s Formula
Chapter 5 Using the Authoring Process
Chapter 6 Written, Dictated, & Electronic Patient Records
Chapter 7 Legal Considerations for Authors of Patient Records
Chapter 8 Practicing the Process
Chapter 9 Analyzing Patient Records
Chapter 10 Authoring Patient Records
Chapter 11 Final Thoughts on the Authoring Process
About the Author(s)
Michael P. Pagano, PA-C, PhD - Department of Communication, Fairfield University
The author is a practicing PA with nearly 3 decades of experience and expertise. He was at one time a Professor and Chair of a PA program in Chicago. He currently works in a Level II Trauma Center/Emergency Department and in an Occupational Health Services Department of a suburban hospital. Over the years, he has worked in numerous medical areas, including surgery, family practice, emergency departments, corporate health, women’s health/family planning and occupational medicine. He intends to use his experience and education to assure that the case studies are accurate representations of communication behaviors and provide a wide array of settings and situations for professors and readers to explore, assess and critique. The author also has his PhD in Communication and will use his health communication background to help illustrate the shortcomings of some of the examples and emphasize interactive ways to help aid assimilation, critical thinking and analyses. Over the years, he has written numerous journal articles, published several textbooks and presented at a host of different conferences.